A woman receives a swine flu vaccination with a jet injector in part of a nationwide campaign that began Oct. 1, 1976.

THIS OUTBREAK DOESN'T FOLLOW PRECEDENTS EXACTLY

Though lessons can be learned from the past, the 2009 H1N1 flu in some ways is strikingly different from the 1976 swine flu, just as the 1976 swine flu turned out to be strikingly different than the 1918 pandemic, says Harvey Fineberg, president of the Institute of Medicine and co-author in 1978 of The Swine Flu Affair:Decision-making on a Slippery Disease.

Unlike the 1976 swine flu, H1N1 cases continue to rise around the world, but today there are effective antiviral drugs. Barry Bloom, Fineberg's successor as dean of the Harvard School of Public Health, says, "My biggest worry in this crisis is that people will overuse Tamiflu and Relenza," leading to flu strains resistant to the antivirals.

Although person-to-person spread of swine flu never reappeared in the 1976-77 flu season, the 1918 Spanish flu laid low during the summer but came back with a vengeance in the fall.

H1N1 would be expected to wane as summer approaches, Fineberg says. "It does not really tell you what will happen in the fall. Could it fizzle? Yes. Could it explode? Yes." Monitoring the situation in the Southern Hemisphere's winter, the Northern Hemisphere's summer, he says, "is going to be very interesting."

Former Health and Human Services secretary Michael Leavitt urged current Cabinet members last week to read The Swine Flu Affair: Decision-making on a Slippery Disease.

The Swine Flu Affair isn't an "instant book" rushed into print because of the worldwide outbreak of H1N1 flu: It was published in 1978, and its title refers to the swine flu of 1976, when public health officials urged all Americans to get immunized against an epidemic that never materialized. Dozens of Americans fell ill with a rare condition linked to the 1976 flu vaccine, and some died.

The ghosts of flu and severe acute respiratory syndrome (SARS) both haunt and inform today's response to H1N1.

When it comes to controlling the flu, says Harvey Fineberg, co-author of The Swine Flu Affair, public health and political leaders seem to have learned that they can prepare to take action without prematurely committing to it.

Just because they've decided to develop an H1N1 vaccine doesn't mean they have to use it. As Anthony Fauci, head of the National Institute for Allergy and Infectious Diseases noted last week, "there's a big difference between having it ready and distributing it."

The 1976 swine flu program was "overwhelmingly recalled as a 'fiasco,' a 'disaster,' or a 'tragedy,' " wrote Fineberg and co-author Richard Neustadt, the late founder of Harvard's Kennedy School of Government.

The government signed off on developing a vaccine and using it at the same time, without ever reassessing the need for immunizing against the unpredictable flu virus.

Specter of the 1918 pandemic

In January 1976, public health officials identified a handful of swine flu cases among new army recruits at Fort Dix, N.J. No subsequent cases of person-to-person swine flu transmission were reported anywhere in the world.

And yet, in March 1976, David Sencer, head of the Centers for Disease Control, wrote a memo comparing the outbreak to the 1918 Spanish flu pandemic, which killed at least 20 million worldwide. Sencer called for mass immunization. Less than two weeks later, President Ford announced he was recommending such a move.

"You can't overstate the specter of 1918 that was hovering in the background," says Fineberg, now president of the Institute of Medicine. "That was the worst natural cataclysm of the 20th century." In addition, he says, when the Hong Kong flu pandemic broke out in early fall 1957, "there was a sense that the vaccine came too late."

So the vaccine for the 1976-1977 flu season included swine flu, Fineberg says, "and the argument was 'Why store it on the shelf? Why not store it in people? Protect them already.' "

The first shots were given Oct. 1, 1976. By Dec. 14, 54 cases of Guillain-Barré syndrome, in which the immune system attacks the nerves, causing paralysis, had been reported in 10 states. Thirty had received the swine flu shot in the month before symptoms appeared.

The government suspended the shots on Dec. 16, but not before 40 million Americans had received them. "The risk of developing Guillain-Barré syndrome seemed to be 11 times greater with vaccination than without," wrote Fineberg and Neustadt. Still, they noted, the risk was remote, about 1 in 105,000.

'Cooler heads are prevailing'

Joseph Califano, who became Jimmy Carter's Health, Education, and Welfare secretary in January 1977, asked Neustadt and Fineberg to investigate the swine flu program "in search of lessons for the future, not of fault in the past," as he writes in their book's introduction.

In an interview this week, though, Califano, chair of the National Center on Addiction and Substance Abuse at New York's Columbia University, placed blame on Sencer. "The guy who was running the CDC wrote a scary memo that was like a gun to the head of the president," said Califano, who fired Sencer. Today, Califano says, "I think cooler heads are prevailing."

Barry Bloom, Fineberg's successor as Harvard School of Public Health dean, also praised public health officials' handling of H1N1: "The world is capable of creating a global alert without creating panic. That's a major difference from SARS." SARS first appeared in China in November 2002, but China didn't tell the World Health Organization until February 2003.

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